ACCUEIL Lire la suite SÉLECTION DE LA TEINTE Lire la suite ESSAI GRATUIT Lire la suite SCIENCE SIMPLE Lire la suite QuestionnaireCompléter uniquement en françaisNom de la personne souffrant d’achromatopsieTitre*Mr.Mrs.Ms.Prénom*Nom*AdresseRue*Adresse ligne 2Ville*État/Province/RégionCode postal*Pays*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsAdresse électronique* Saisir l’adresse électronique Confirmer l’adresse électronique Numéro de téléphone pour contactPréfixe93 Afghanistan355 Albania213 Algeria1-684 American Samoa376 Andorra244 Angola1-264 Anguilla672 Antarctica1-268 Antigua and Barbuda54 Argentina374 Armenia297 Aruba61 Australia43 Austria994 Azerbaijan1-242 Bahamas973 Bahrain880 Bangladesh1-246 Barbados375 Belarus32 Belgium501 Belize229 Benin1-441 Bermuda975 Bhutan591 Bolivia387 Bosnia and Herzegovina267 Botswana55 Brazil246 British Indian Ocean Territory1-284 British Virgin Islands673 Brunei359 Bulgaria226 Burkina Faso257 Burundi855 Cambodia237 Cameroon1 Canada238 Cape Verde1-345 Cayman Islands236 Central African Republic235 Chad56 Chile86 China61 Christmas Island61 Cocos Islands57 Colombia269 Comoros682 Cook Islands506 Costa Rica385 Croatia53 Cuba599 Curacao357 Cyprus420 Czech Republic243 Democratic Republic of the Congo45 Denmark253 Djibouti1-767 Dominica1-809, 1-829, 1-849 Dominican Republic670 East Timor593 Ecuador20 Egypt503 El Salvador240 Equatorial Guinea291 Eritrea372 Estonia251 Ethiopia500 Falkland Islands298 Faroe Islands679 Fiji358 Finland33 France689 French Polynesia241 Gabon220 Gambia995 Georgia49 Germany233 Ghana350 Gibraltar30 Greece299 Greenland1-473 Grenada1-671 Guam502 Guatemala44-1481 Guernsey224 Guinea245 Guinea-Bissau592 Guyana509 Haiti504 Honduras852 Hong Kong36 Hungary354 Iceland91 India62 Indonesia98 Iran964 Iraq353 Ireland44-1624 Isle of Man972 Israel39 Italy225 Ivory Coast1-876 Jamaica81 Japan44-1534 Jersey962 Jordan7 Kazakhstan254 Kenya686 Kiribati383 Kosovo965 Kuwait996 Kyrgyzstan856 Laos371 Latvia961 Lebanon266 Lesotho231 Liberia218 Libya423 Liechtenstein370 Lithuania352 Luxembourg853 Macau389 Macedonia261 Madagascar265 Malawi60 Malaysia960 Maldives223 Mali356 Malta692 Marshall Islands222 Mauritania230 Mauritius262 Mayotte52 Mexico691 Micronesia373 Moldova377 Monaco976 Mongolia382 Montenegro1-664 Montserrat212 Morocco258 Mozambique95 Myanmar264 Namibia674 Nauru977 Nepal31 Netherlands599 Netherlands Antilles687 New Caledonia64 New Zealand505 Nicaragua227 Niger234 Nigeria683 Niue850 North Korea1-670 Northern Mariana Islands47 Norway968 Oman92 Pakistan680 Palau970 Palestine507 Panama675 Papua New Guinea595 Paraguay51 Peru63 Philippines64 Pitcairn48 Poland351 Portugal1-787, 1-939 Puerto Rico974 Qatar242 Republic of the Congo262 Reunion40 Romania7 Russia250 Rwanda590 Saint Barthelemy290 Saint Helena1-869 Saint Kitts and Nevis1-758 Saint Lucia590 Saint Martin508 Saint Pierre and Miquelon1-784 Saint Vincent and the Grenadines685 Samoa378 San Marino239 Sao Tome and Principe966 Saudi Arabia221 Senegal381 Serbia248 Seychelles232 Sierra Leone65 Singapore1-721 Sint Maarten421 Slovakia386 Slovenia677 Solomon Islands252 Somalia27 South Africa82 South Korea211 South Sudan34 Spain94 Sri Lanka249 Sudan597 Suriname47 Svalbard and Jan Mayen268 Swaziland46 Sweden41 Switzerland963 Syria886 Taiwan992 Tajikistan255 Tanzania66 Thailand228 Togo690 Tokelau676 Tonga1-868 Trinidad and Tobago216 Tunisia90 Turkey993 Turkmenistan1-649 Turks and Caicos Islands688 Tuvalu1-340 U.S. Virgin Islands256 Uganda380 Ukraine971 United Arab Emirates44 United Kingdom1 United States598 Uruguay998 Uzbekistan678 Vanuatu379 Vatican58 Venezuela84 Vietnam681 Wallis and Futuna212 Western Sahara967 Yemen260 Zambia263 ZimbabweTéléphone*À propos de vousAvez-vous plus de 12 ans ?OuiNonÂge12-2021-3031-45Above 45À quel âge l’achromatopsie a-t-elle été diagnostiquée ?Êtes-vous suivi par un ophtalmologue/professionnel de la vue titulaire d’une licence ?*OuiNonPortez-vous des lunettes teintées ?OuiNonDans l’affirmative, de quelle teinte/couleur et marque ?Avez-vous déjà porté des lentilles de contact ?*OuiNonAvez-vous déjà porté des lentilles de contact teintées ?*OuiNonDans l’affirmative, de quelle teinte/couleur et marque ? Adresse de livraison autre que l'adresse mentionnée ci-dessusPrénomNom*CompanyRue*Adresse ligne 2Ville*État/Province/RégionCode postal*Pays*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsAutres informations que vous souhaiteriez nous communiquerFichierTaille max. des fichiers : 512 MB. 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